Healthy Alaskans 2020

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Actions for Success

Process

Team Organization

Contact:

healthyalaskans@alaska.gov

State of Alaska -
Division of Public Health
Lisa DH Aquino, MHS
Community Health Improvement Manager
3601 C Street
Anchorage, AK 99503
(907)269-3456


Alaska Native Tribal Health Consortium - Division of
Community Health Services

Emily Read
Operations Director
3900 Ambassador Drive, Suite 401
Anchorage, AK 99508
(907) 729-3941


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Evidence-based Strategies:
22. Reduce preventable hospitalizations

Alaska Strategies

  1. Increase access to high quality primary care.

  2. Improve care coordination, community care transitions, and complex case management.

  3. Strengthen community-based and clinical prevention to improve population health.

Click here for detailed information about these strategies.


Other Strategies

Transitional Care Model

Description: A nurse-led hospital discharge and home follow-up program for chronically ill older adults.

Specific Programs/Strategies: The Transitional Care Model is designed to prevent health complications and rehospitalizations of chronically ill, elderly hospital patients by providing them with comprehensive discharge planning and home follow-up, coordinated by a master’s-level “Transitional Care Nurse” who is trained in the care of people with chronic conditions.

  • Target Audience: Older Adults
  • Setting: Clinical
  • Recommendation: Recommended
  • Review Agency: Community Guide
  • Related Topics: Not applicable
  • Website: Transitional Care Model

Increase Wages for Long-term care (LTC) Workers

Description: What Works for Health: Increase Wages for Long-term care (LTC) Workers. LTC Workers provide care to clients in a variety of settings, such as in-home care, nursing homes, and rehabilitation facilities. Patients are generally the elderly, individuals with disabilities, or recovering from injuries; hands-on, physically demanding care is often needed. Many workers are employed part-time and have little opportunity for advancement . There is strong evidence that increasing wages and benefits for long-term care workers increases the size and stability of the direct care workforce.

Specific Programs/Strategies: Offering better wages and benefits is a suggested strategy to improve recruitment and retention of individuals that provide long-term care.Increasing the wages and other benefits available to long-term care workers reduces turnover, particularly among newly hired caregivers. Providing health insurance for part-time workers can both attract new employees and help employers maintain existing workers.

Health Care Innovations Exchange Service Delivery Innovation Profile

Description: AHRQ Health Care Innovations Exchange Service Delivery Innovation Profile. Peer Coaching Combined With Nurse Outreach Improves Adherence to Medical Recommendations Among Elderly Cardiac Patients Who Live Alone Following Discharge

Specific Programs/Strategies: A nurse-guided, patient-centered approach that combines ongoing peer support from a trained elder with home visits and followup phone calls from an advanced practice nurse for unpartnered, elderly patients who are discharged from the hospital after a heart attack or bypass surgery. The program is intended to encourage compliance with medication regimens and recommended lifestyle changes, with the goal of reducing hospital readmissions. A randomized controlled trial found that the program improved adherence to medical recommendations and reduced hospitalizations due to cardiac-related complications but failed to reduce overall hospital readmissions.

Peer Coaching Combined with Nurse Outreach

Description: AHRQ Health Care Innovations Exchange Service Delivery Innovation Profile. Peer Coaching Combined With Nurse Outreach Improves Adherence to Medical Recommendations Among Elderly Cardiac Patients Who Live Alone Following Discharge

Specific Programs/Strategies: A nurse-guided, patient-centered approach that combines ongoing peer support from a trained elder with home visits and followup phone calls from an advanced practice nurse for unpartnered, elderly patients who are discharged from the hospital after a heart attack or bypass surgery. The program is intended to encourage compliance with medication regimens and recommended lifestyle changes, with the goal of reducing hospital readmissions. A randomized controlled trial found that the program improved adherence to medical recommendations and reduced hospitalizations due to cardiac-related complications but failed to reduce overall hospital readmissions.

  • Target Audience: Older Adults
  • Setting: Clinical
  • Recommendation: Strong Evidence
  • Review Agency: AHRQ Health Care Innovations Exchange
  • Related Topics: Not applicable
  • Website: Peer Coaching Combined with Nurse Outreach

Re-Engineered Discharge project (Project RED)

Description: AHRQ Health Care Innovations Exchange Service Delivery Innovation Profile. Standardized Discharge Planning Focusing on Patient Education and Care Coordination Increases Understanding of Postdischarge Needs and Likelihood of Followup Care.

Specific Programs/Strategies: The Re-Engineered Discharge project (Project RED) standardizes the hospital discharge process through the use of 11 separate but mutually reinforcing steps that health care professionals follow from patient admission to postdischarge. The steps incorporate the provision of patient education, care coordination with primary care physicians, and postdischarge followup with a pharmacist. The program reduced the rate of hospital readmissions and emergency department visits in the first month after discharge, improved patients’ understanding of postdischarge needs, and increased the likelihood of timely followup care.

Technology-Enabled Referral Relationship

Description: AHRQ Health Care Innovations Exchange Service Delivery Innovation Profile. Formalized, Technology-Enabled Referral Relationships Between Medical Center and Community Clinics Enhance Access and Reduce Inappropriate Emergency Department Visits

Specific Programs/Strategies: Emergency department (ED) patients with nonemergent conditions get connected to a medical home (rather than being treated), while patients receiving primary care from Federally Qualified Health Centers (FQHCs) and county clinics gain access to specialty care. An electronic referral system within the ED allows personnel to directly schedule same-day primary care appointments at a Federally Qualified Health Center. A toll-free telephone line allows community-based providers to arrange specialist appointments at the medical center, while video equipment gives providers the capability to confer with university-based specialists as necessary. The program has enhanced access to primary care, reduced return ED visits, and generated significant cost savings

  • Target Audience: All ages
  • Setting: Clinical
  • Recommendation: Moderate Evidence
  • Review Agency: AHRQ Health Care Innovations Exchange
  • Related Topics: Not applicable
  • Website: Technology-Enabled Referral Relationship

Cathedral Square Support and Services at Home

Description: AHRQ Health Care Innovations Exchange Service Delivery Innovation Profile. Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health

Specific Programs/Strategies: The Cathedral Square Support and Services at Home program provides onsite assistance to help senior citizens (and other Medicare beneficiaries) remain in their homes as they age. Using evidence-based practices, key services include an initial assessment by a multidisciplinary onsite health team, creation of an individualized care plan, onsite nursing and care coordination with team members and other local partners, and community activities to support health and wellness. In a year-long pilot test with 65 residents, the program reduced hospital admissions and readmissions, had no bounce backs to nursing homes, decreased falls, improved nutritional status, and increased levels of physical activity.